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Understandings of reproductive tract infections in a peri-urban pueblo joven in Lima, Peru


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Research article

Understandings of reproductive tract infections in a peri-urban

pueblo joven in Lima, Peru

Lisa Scipioni Hernández


, Peter J Winch*


, Kea Parker



Robert H Gilman


Address: 1Independent Consultant, New York, New York, USA, 2Department of International Health, Johns Hopkins Bloomberg School of Public

Health, Baltimore, Maryland, USA and 3Medical Student, Leonard M. Miller School of Medicine at the University of Miami, Miami, Florida, USA

Email: Lisa Scipioni Hernández - lisascip@hotmail.com; Peter J Winch* - pwinch@jhsph.edu; Kea Parker - kea_parker@hotmail.com; Robert H Gilman - rgilman@jhsph.edu

* Corresponding author †Equal contributors


Background: Control programs for Reproductive Tract Infections (RTIs) typically focus on increasing awareness of risks associated with different forms of sexual contact, and pay little attention to how or why people may link RTIs to other features of their physical or social environments. This paper describes how women in a peri-urban pueblo joven located in the coastal desert surrounding Lima, Peru conceptualize the links between RTIs, sexual behaviour, personal hygiene, and the adverse environment in which they live.

Methods: We combined qualitative interviews and a participatory voting exercise to examine social and physical environmental influences on RTIs and gynaecologic symptom interpretation.

Results: Knowledge of RTIs in general was limited, although knowledge of AIDS was higher. Perceived causes of RTIs fell into three categories: sexual contact with infected persons, personal hygiene and exposure to the contaminated physical environment, with AIDS clearly related to sexual contact. The adverse environment is thought to be a major contributor to vaginal discharge, "inflamed ovaries" and urinary tract infection. The more remote parts of this periurban squatter settlement, characterized by blowing sand and dust and limited access to clean water, are thought to exhibit higher rates of RTIs as a direct result of the adverse environment found there. Stigma associated with RTIs often keeps women from seeking care or obtaining information about gynaecologic symptoms, and favours explanations that avoid mention of sexual practices.

Conclusion: The discrepancy between demonstrated disease risk factors and personal explanations influenced by local environmental conditions and RTI-related stigma poses a challenge for prevention programs. Effective interventions need to take local understandings of RTIs into account as they engage in dialogue with communities about prevention and treatment of RTIs.


Reproductive Tract Infections (RTIs) are a major cause of ill health globally [1,2]. RTIs can be caused by sexually

transmitted infections (STIs), overgrowth of organisms normally present in the reproductive tract, and medical and surgical procedures including insertion of

intrauter-Published: 02 May 2006

BMC Women's Health 2006, 6:7 doi:10.1186/1472-6874-6-7

Received: 17 January 2006 Accepted: 02 May 2006

This article is available from: http://www.biomedcentral.com/1472-6874/6/7

© 2006 Hernández et al; licensee BioMed Central Ltd.


ine devices and induced abortions. In women, RTIs can be asymptomatic, and even when symptomatic their presen-tation can overlap with and be misdiagnosed as normal physiologic change, and normal physiologic discharge may be misdiagnosed as RTI [3]. RTIs are extremely com-mon in Peru. A recent study on RTIs conducted on a sam-ple drawn from the coastal, highland and jungle regions of Peru found that 77% of women reported symptoms compatible with RTIs, 70.4% were found positive for at least one RTI and 38.4% were positive for two or more RTIs [4]. Bacterial vaginosis was found in 43.7% of the sample, trichomoniasis in 16.5%, vulvovaginal candidia-sis in 4.5%, Chlamydia in 6.8%, gonorrhoea in 1.2% and cervical human papilloma virus infection in 4.9% [4]. Another recent study on herpes simplex virus type 2 (HSV-2) found a 20.5% prevalence in women and 7.1% in men in the general population in coastal Peru [5].

This paper focuses on local understandings of the causa-tion (aetiology) of RTIs in peri-urban Lima, Peru, and ways in which women link the occurrence of RTIs to envi-ronmental and living conditions in the communities

where they live. Local models of illness causation are only one aspect of a larger pattern of cultural response to RTIs, but they have been a specific focus of qualitative studies on RTIs for several reasons. First, rates of careseeking for RTIs from allopathic (cosmopolitan medical) providers are generally reported to be low. There is an assumption, often not clearly articulated in research reports, that if women ascribe RTIs to infectious agents they will be more likely to utilize modern medical care including antibiot-ics, whereas if they ascribe RTIs to other causes such as lack of personal hygiene, adverse environmental condi-tions, dietary imbalance or supernatural forces, they will try other treatments such as traditional remedies. A sec-ond assumption is that, if it is not understood that sexual contact is an important cause of RTIs, this may favour the adoption of prevention methods unrelated to safer sexual practices such as changes in diet or wearing of amulets.

Table 1 summarizes the perceived causes of RTIs including sexual transmission reported in six qualitative studies [6-11] and one quantitative study from Brazil [12]. This pres-entation is illustrative rather than comprehensive, and

Table 1: Perceived causes of reproductive tract infections among informants reported in seven primarily qualitative studies

Causes of RTIs mentioned by study participants Pakistan Bangla-desh Vietnam Liberia South Africa Uganda Brazil [6] [7] [8] [9] [10] [11] [12]


1.1 Sexual contact with infected persons

No Yes Yes Yes Yes Yes Yes 1.2 Personal hygiene Hygiene before and after sexual


No No Yes No Yes No No Infrequent washing of genitals,

unclean undergarments or towels

Yes No Yes Yes Yes Yes Yes Poor hygiene during or after


No No Yes No No No No Sharing toilets, dirty toilets No No No Yes No Yes Yes 1.3 Exposure to contaminated

physical environment

Exposure to contaminated water Yes No Yes No No No No Exposure to contaminated soil, dirt

or dust carried by air

Yes No No Yes No No No Stepping in infected urine No No No Yes No No No 1.4 Pubic lice, other biting insects No No No No Yes Yes No 1.5 Surgical procedures: IUD insertion, tubal ligation, induced


Yes Yes Yes No No No No 1.6 Intravenous drug use No No No No No No Yes


2.1 Diet, dietary imbalance Yes No Yes Yes No No No 2.2 Weakness or excessive

demands on body

Hard work No Yes No No No Yes No Weakness Yes No No No No No No Pregnancy and childbirth Yes Yes No No No No No



were selected from approximately 35 qualitative studies on RTIs identified through a search on PubMed because 1) they provided significant detail (at least three para-graphs) on local understandings of RTI causation and 2) they represent a range of settings. In the interest of brevity, not every possible cause reported in these 7 articles is included in Table 1. Although it is difficult to discern an overall pattern to the perceived causes cited in Table 1 and other articles, RTIs are primarily attributed to contamina-tion with germs or unclean substances through various routes such as sexual contact, ingestion of contaminated food, use of unclean needles, or an internal imbalance or over-exertion. The action of malevolent agents is signifi-cant in some settings, leading people to take measures to protect themselves from spirits [7], or consult traditional practitioners who specialize in illnesses related to witch-craft and sorcery [10,11,13]. The concept of contamina-tion may include the transfer of infectious agents occurring through sexual and other forms of contact, but also includes concerns about exposure to dirt. Linking of the concept of contamination to notions of purity and pollution are most prevalent in South Asia [6,7,14].

While sexual transmission is often the most commonly mentioned cause, in one study in Karachi, Pakistan, none of the women interviewed nor the health care providers they had consulted had suggested sexual transmission as a possible cause of RTIs [6]. Results from Vietnam are typ-ical of many studies, where "almost every woman knows that some infections can be sexually transmitted, but they consistently report that it is not the case for their own symptoms" [8]. Stigma associated with sexual transmis-sion of diseases commonly appears to lead both men and women to favour other causal explanations.

Personal hygiene stands at the intersection of many causal explanations, and is a common way informants attempt to lessen the risks of sexual relations they may not be in a position to avoid. Personal hygiene may include washing before and after sexual relations, wearing clean undergar-ments, avoiding contact with toilet seats and using disin-fectants. In Kenya, Nzioka reports that "the act of washing or taking a shower which lead to physical cleanliness" is a form of safer sex [15]. A study in North India found nearly half the young men in a survey believed that washing the penis with a disinfectant after sex helped prevent disease, and 30–40% continued to believe that urinating after sex reduced the chances of transmission of sexually-transmit-ted infections, even at the conclusion of an intensive com-munity-based education intervention [16].

Personal hygiene is also thought to be the vehicle through which the physical environment (exposure to dirt, dust, dirty water) increases the likelihood of RTIs. When the physical environment is mentioned as having a role in

RTIs, personal hygiene is usually mentioned as a factor mediating that effect. In Vietnam, working waist deep in water is seen as a prime cause of RTIs, and has two aspects: exposure to infection through the dirty water itself, and the dampness itself, spending all day in damp clothing [8]. Women reported douching with a solution contain-ing boiled guava leaves and salt to "dry out the vagina" [8].

In this paper we describe the links women in a peri-urban neighbourhood near Lima, Peru make between RTIs and the physical environment in which they live, and how they perceive that the risk of RTIs varies according to where one lives. These data will demonstrate that manag-ers of programs seeking to reduce the impact of RTIs need to take into consideration not only the social environ-ment in which people live, including gender relations, but also their physical environment and neighbourhood char-acteristics.


Study site

Research was conducted in Las Pampas de San Juan de Miraflores, a peri-urban pueblo joven (young town), located 15 kilometres south of urban Lima with a total population of 40,700. Physically, this environment con-sists of steep and rocky desert hills with dusty soil, no nat-ural vegetation, and less than one inch of rainfall a year. A low layer of clouds, created when cold Pacific winds meet the Andes mountain range to the east of Lima, covers the city for 9 months of the year [17].

Pueblos jovenes are nearly always formed by well-planned community efforts, often in the form of illegal "land invasions" [18]. Literally overnight, prospective res-idents occupy an undeveloped tract of land and each fam-ily quickly constructs a home using whatever material is available. As communities grow, economic distinctions become visible; more established residents live in lower elevations, have homes built with cement blocks and have better access to resources and transportation. We will refer to these areas as "modern" Pampas. Homes located at higher elevation are built with woven bamboo mats, plas-tic, and other scavenged material. These areas are occu-pied by more recent arrivals to the community and we will refer to them as "marginal" Pampas. Inhabitants of pueb-los jovenes work together to transform newly formed set-tlements into communities equipped with amenities such as water, electricity, schools, medical centres, and police stations [17].


from $850 to $4600 per year [19]. Most households have electricity but only about half have water or sewage con-nections. For those without water connections, water must be purchased either from neighbours with connec-tions, from private water sources, or from pilones, water connections whose service and expense are shared by neighbours. In part because of this, water use is extremely low. Families in Las Pampas on average use only 75 litres of water a day and less than 15% of total water is used for bathing [20]. Bathroom facilities for residents without indoor plumbing are called silos (outhouses) and are often shared by numerous families.

Semi-structured interviews

During the 7 weeks between October 21 and December 10, 1997 the first author was located at a health post serv-ing Las Pampas de San Juan de Miraflores with a female paramedic specialized in women's health or obstetriz. Women who came to the health post to visit the obstetriz specifically were asked if they would be willing to partici-pate in the study. The obstetriz and researcher were present in the health post from 10-3 Monday-Thursday. The health post was staffed by a physician Mondays-Thursdays during the same time. All women who attended the health post were invited to participate in semi-structured interviews. Interviews were conducted in a private room in the health post. Approximately 200 women were approached to participate, and 32 agreed to participate in the study. Of these, 3 agreed to and com-pleted an additional interview. Interviews lasted between 1 and 2 hours. Topics covered included: community health concerns; RTI awareness, prevention, causes, and available treatment; and social factors affecting sexuality and health seeking behaviour. Interviews and activities took place in Spanish and were carried out by the same female researcher (L.S.H.). Those who declined to partici-pate mentioned time constraints and apprehension in dis-cussing the subject matter as reasons for not participating. Ages ranged from 17 to 45 years; 69% of respondents were between 20 and 34 years old and the mean age was 28. All participants were self-reported mestizo (of mixed indige-nous and Spanish background). One of the women reported no formal education and three had completed university training. The majority (68%) had some second-ary education but had not finished high school. Most (66%) of the respondents were not born in Lima. Age at first sexual relation was 8–9 (1 respondent), 10–15 (3 resp.), 16–19 (19 resp.) and 20–24 (9 resp.). The first partner was reported to be a friend (1 resp.), boyfriend (18 resp.), spouse (5 resp.), roommate (3 resp.), stranger (2 resp.), family member (1 resp.) or the first encounter was as a victim of rape (2 resp.). The reported number of lifetime partners was 1 (16 resp.), 2 (3 resp.), 3 (10resp.) and more than 3 (2 resp.) with a mean of 2. Three of the women reported ever having used condoms. Interviews

were tape recorded with the participant's consent and then translated into English. Responses were searched, coded thematically, and analyzed using Nud*ist (Non-numerical Unstructured Data Indexing Searching and Theorizing) software (Version 4, 1997).

Participatory exercise on illness occurrence and distribution

In a subsequent phase of the study, participatory data col-lection was conducted with a different subpopulation of the Las Pampas community. Women were visited in their homes and 23 were selected on the basis of their geo-graphic distribution throughout Las Pampas and their willingness to participate. Approximately equal numbers were selected from women living in completed concrete box houses, women living in concrete houses under con-struction and women in marginal areas living in houses made of scrap materials. A participatory method was uti-lized to examine how they perceived geographic variation and risk of a range of reproductive health problems. Respondents were asked where certain diseases or symp-toms associated with sexuality (vaginal discharge, "infec-tion in the ovaries", urinary tract infec"infec-tion, AIDS and venereal diseases) occurred most frequently in their com-munity and their reasons for this perception of disease occurrence. To answer this, participants were asked to dis-tribute 8 beans between pictorial representations of four geographic areas according to what they perceived to be the relative frequency of occurrence of different health problems in each location. It was felt that these four geo-graphic areas represented four distinct environments that are familiar to all residents of Las Pampas and frequently alluded to in interviews. The four locations used for this exercise were:

1. Sierra or Highlands – Rural and relatively traditional highland communities, where indigenous languages are frequently spoken, one of the main sources of migrants settling in pueblos jovenes (Young towns);

2. "Marginal" Pampas – Area within the pueblo joven of Las Pampas that is the least established, most recently devel-oped, farthest from main roads, and highest on the sur-rounding hills. Structures in this area are mostly made of woven straw matting, cardboard, and corrugated iron, and rarely have electricity, sewage, or water services;

3. "Modern" Pampas – Area within the pueblo joven of Las Pampas that is more established than the marginal com-munities and is located closer to main roads. Most struc-tures are concrete with electricity, sewage, and water connections; and


Ethical approval for this project was received from the Internal Review Board at Johns Hopkins University and A.B. PRISMA, the sponsoring Peruvian non-governmental organization with which we collaborated. We received written, informed consent from all participants and confi-dentiality was assured and maintained in every aspect of this study.


Awareness of RTIs and AIDS and local terminology

The level of knowledge about RTIs in general was low. When asked about health problems in the community, only one woman mentioned RTIs or AIDS in her initial response. Another respondent, when asked if RTIs were a problem in her community, responded:

"I don't think so. I don't think so. Like I say, it may be the case that women have this disease and men have these diseases but they don't say it, they don't talk about it and well, they go and cure themselves, but they talk about this very little. I have heard little about venereal disease maybe because people don't talk about it. They don't talk."

Blame was placed on individuals for their lack of knowl-edge. One respondent explained:

"Ah, a lot of women don't know about these diseases. Yes, I know because I always go to the health post, with the gynaecol-ogists, they explain it...there are a lot of women that are una-ware of all this, they don't know because they don't go to the health posts or they don't prepare. There are uninformed hus-bands that don't explain to their wives all this; yes there are a lot of women that do not know any of these things. The health posts are there to orient us about this, but there are women that are lazy."

In contrast, another respondent stated:

"At the health post they give us very little information. Some-times women don't go because they are embarrassed, they don't inform us enough."

Respondents stated that it was often embarrassing to go to the main health post to seek treatment for a gynaecologic infection, and that the social consequences of being per-ceived as having a RTI could be more detrimental than the infection itself.

Participants appeared to lack specific vocabulary to describe sexually transmitted diseases, gynaecologic symptoms, or the female genital region. Most women were familiar with the term SIDA (Spanish acronym for AIDS) and when women appeared confused by the terms

Enfermedades Transmitadas Sexualmente (Sp. sexually trans-mitted disease) and Enfermedades venereas (Sp. venereal

diseases) the researcher occasionally would resort to the explanation that they are diseases "like SIDA". The Span-ish translation for sexually transmitted infection was not familiar at all to respondents. When referring to sexual transmission of disease, terms such as contagio (Sp. conta-gion), infectado (Sp. infected) and quemarse (Sp. to burn oneself) were used by the respondents. The latter is used in ways such as lo quemaste (Sp. you burned him) imply-ing "you infected him with a sexually-transmitted infec-tion". Infecciones de los ovarios (Sp. infections of the ovaries) is a term commonly used to describe lower abdominal pain that may be accompanied by vaginal dis-charge. Descensos (Sp. Unloading, discharge) or enferme-dades de la mujer (Sp. illnesses of women) are terms used to describe vaginal discharge. Abajo (Sp. below) was used to describe the female abdominal or genital region.

Perceived causes of RTIs: sexual contact with infected persons

Referring to the classification of perceived causes of RTIs in Table 1, the causes mentioned by study participants all fell into three categories: sexual contact with infected per-sons, personal hygiene and exposure to the contaminated physical environment. Biting insects, surgical procedures, drug use, diets and the actions of malevolent agents such as spirits were not mentioned, although hard work was mentioned in relation to the adverse environment.

A number of participants referred to sexual transmission as a cause of RTIs. Nevertheless, women reported that they are discouraged from appearing informed regarding sexu-ality. Thus even if women are aware of biomedical models of transmission, other causes related to personal hygiene or the physical environment are more acceptable as expla-nations for disease symptoms.

"Concerning sexuality, there are many taboos for women, they should not appear to be informed."

Health care workers are aware of the stigma associated with sexual transmission of diseases, and may avoid con-fronting clients about this issue. One respondent who tested positive for Chlamydia asked:

"Tell me is it sexually transmitted? Because when I went to the doctor, when my disease began recently...the doctor told me, 'don't worry, they came about because of the humidity' he didn't tell me that it was sexually transmitted."


"Because who knows if they have other women in another place that can infect us."

Perceived role of sexual contact in AIDS transmission

Women in our study often did not clearly distinguish between AIDS and other RTIs, but they were much clearer about the relation between AIDS transmission and sexual contact than they were for other RTIs referred to by terms such as vaginal discharge or inflamed ovaries. Due in part to success of recent AIDS awareness campaigns [21], most of our respondents understood that AIDS could be trans-mitted sexually or through blood,

"(AIDS can be transmitted) through sex and if the blood of an infected person runs into that of a healthy person."

Our mostly monogamous informants noted multiple partners and commercial sex work as factors influencing the spread of AIDS.

"People get infected with AIDS through relations. There are men that want to have four or five women and there is one woman that has the disease and this is how they are transmit-ted."

"If a person stays in their house, they can't get infected with this, but those that go to the streets (for sex) can."

However, a great number of informants thought a number of additional modes of transmission existed, often through apparently casual contact.

"AIDS is transmitted through food or through a kiss."

"Through hair cuts, it could happen at the hairdressers, in the same case someone could get infected through blood"

"Another way is in bathrooms, those women go to the bathroom and they get infected"

"Through conversation"

Perceived causes of RTIs: personal hygiene

Personal hygiene was a common explanation for the occurrence of RTIs other than AIDS. Good personal hygiene was viewed as a way of decreasing the possibility of both disease transmission from a partner, and contam-ination from the surrounding environment:

"Depends on the cleanliness of the woman, of the man also...(disease comes) when we don't wash."

As in Vietnam [8], dampness was a major concern. It was common for women to mention the importance of clean undergarments in preventing transmission:

"My mother said to me, it is because I use her underwear. I think that it started because of this and she told me not to use her underwear."

One respondent who tested positive for trichomoniasis and Chlamydia explained how she became infected:

"It must be after I went to the bathroom to urinate and wet my underwear and didn't change them."

When asked if she thought it could be due to sex, she responded:

"No, my partner is very careful with this."

"Careful" may refer to personal hygiene, rather than to use of condoms and avoidance of multiple partners.

"Before having a sexual relation they must both practice good hygiene"

"...when one already has sexual contact you have to clean up despite the fact that you have sex with your husband, by all means he must clean before he has sex with us."

Some women felt the cause of disease was more related to personal hygiene than multiple partners:

"Because maybe the husband goes to bed with some women that aren't clean and those women maybe are women of the streets, or also when women don't wash themselves well, I think that this is how it must be."

Problems related to personal hygiene were seen as partic-ularly common in Las Pampas due to shortages of water, especially at higher elevations, making it difficult for women to wash regularly.

Perceived causes of RTIs: adverse physical environment


"This is a problem here mostly because of the poverty, we don't have water. In the provinces we have water in the river – here there is more dust, dirt, sand and filth."

Other women explained that symptoms come:

"From the sand, sometimes we feel it when we wear skirts"

or because:

"It is not so clean here, there are microbes in the dirt."

The second mechanism is overwork, and overexposure to cold winds, which could be classified as an imbalance according to Table 1. Both "infection in the ovaries" and vaginal discharge were commonly related to the physi-cally gruelling lifestyle that often involves walking and carrying water and heavy loads within Las Pampas.

"(infection in the ovaries comes) from the cold, there is too much wind"

"They walk more here, it is because of the height of where they live, to go to work, they go up, and they go down these cliffs – too much travel."

Another respondent states that the combination of expo-sure to dirt and lack of money to purchase soap was what most aggravated the situation:

"This disease comes because there is much work and much walking...they walk through the sand and the dirt, they are walking through the dirt, through the dust and they don't have money to wash with soap."

Perceived geographic variation in RTIs

Table 2 illustrates the results of a participatory voting exer-cise (N = 23 participants) where each participant was

given 8 beans to distribute among the four zones accord-ing to the perceived geographic variation in occurrence of the condition in question. If a participant placed one or two beans on each of the four local terms for RTIs (vaginal discharge, inflamed ovaries, urinary tract infection, sexu-ally-transmitted infections) and AIDS, the interpretation was that the participant did not perceive there to be a strong association between illness occurrence and the four different environments (rural highlands, marginal/ recently settled areas of Las Pampas, modern/more estab-lished areas of Las Pampas and urban Lima), while plac-ing all or most beans on one environment was interpreted as a strong association between illness occurrence and environment.

Table 2 shows that three of the conditions, vaginal dis-charge, inflamed ovaries and urinary tract infection were rated by respondents during the voting exercise as far more common in the marginal areas of Las Pampas. Sex-ually-transmitted infections were rated as slightly more common in the marginal areas of Las Pampas, while AIDS was rated as more common in urban Lima. To explain these results, it is necessary to consider once more the three most common categories of perceived causes for RTIs (Table 1): sexual contact with infected persons, per-sonal hygiene and contaminated physical environment.

Sexual contact, according to respondents, is associated with AIDS, and is uncommonly associated with vaginal discharge, inflamed ovaries and urinary tract infection. Urban Lima was associated with unsafe sexual practices, especially commercial sex work, and that is the main rea-son participants rated urban Lima as the most common site for AIDS and the second most common site for the occurrence of sexually-transmitted infections. When asked why, women responded that the social environ-ment of Lima was responsible. A higher prevalence of

Table 2: Perceived relative abundance/frequency of reproductive tract infections in four different geographic areas, as assessed through a participatory voting exercise with 23 representatives of Las Pampas. Each participant was given 8 beans to distribute among the four areas according to the perceived geographic variation in occurrence of the condition in question. We interpreted an equal distribution of beans throughout the pictures (2 beans per picture) as no geographic association, whereas 8 beans on one picture was interpreted as high geographic association.

Geographic areas Percent of beans assigned to each geographic area (Assessment performed separately for each illness term)

Allocation of beans across all five conditions Vaginal


Inflamed Ovaries

Urinary Tract Infection

AIDS Sexually transmitted infections

Rural-Highlands 9% 17% 13% 9% 10% 12% Marginal-Pampas 67% 59% 70% 26% 39% 53% Modern-Pampas 21% 18% 11% 23% 23% 19% Urban Lima 3% 8% 6% 43% 28% 16% Total Beans Assigned 184 184 159* 160* 145* 832


prostitution and more liberal women inside the city were seen as reasons for these diseases.

"Maybe he can have other partners because he is here in Lima, here the girls offer themselves for sex."

The adverse environment is thought to be a major contrib-uting factor to vaginal discharge, inflamed ovaries and uri-nary tract infection, and the marginal areas of Las Pampas are thought to have the most adverse environment. Nei-ther vaginal discharge nor "infection in the ovaries" was viewed as a problem in urban Lima:

"They don't have this in Lima because Lima is clean."

Features of the social environment that favour alternative explanations

"As women, we are always suffering, when we have sex we have pain or we get an infection."

Ascribing of RTIs to alternative explanations such as defi-cient personal hygiene or to the adverse physical environ-ment occurs in a setting where women have little or no control over sexual decision-making. Gender roles in Peruvian society are strongly dictated by traditional Latin American interpretations of what it means to be a woman or man. These social dictates give men control over sexual decisions and often leave women unable to alter disease risk. A respondent explained her failed attempt at using protection with her husband:

"He doesn't want me to use protection because he thinks that then I could have sex with another person"

Economic and social dependence on men strongly affected the willingness of women to address concerns related to sex. Machismo present in many Latin American countries is viewed as an important factor in this.

"...Machismo is generally the result of lack of female educa-tion.... Because men provide economic support, females feel submissive under the male domain...you always live dependent on men.... Men don't lose."

"El hombre es hombre" or "men are men" was a quote used by three of the women participating in this study.

"...men are men...sometimes he uses you sexually, then what happens--- sometimes we forget how men are."

Our respondents were quick to dismiss male responsibil-ity in sexual relations but some acknowledged men's role in disease occurrence.

"Men are men, they use pleasure how they want and they don't use protection and this is how the disease comes."


In this exploratory study, we examined the influence of the physical and social environment on women's percep-tions of RTIs and gynaecologic symptoms. These data are of programmatic significance because they highlight rea-sons why women deny or underestimate their personal RTI risk, and can contribute to improved approaches to communicating with women about RTI prevention. Knowledge of sexual contact as one way of transmitting RTIs was high, particularly for AIDS. However, the per-ceived personal risk of acquiring other RTIs through sex-ual contact was low.

The stigma associated with RTIs in women hinders treat-ment and discourages communication with sexual part-ners about such infections [22,23]. This stigma contributes to models of gynaecologic symptoms and infections that exclude sexual contact with infected per-sons as an explanation.

At the same time, other features of the physical and social environment may affect the quality of life on a daily basis and "pull" people toward external explanations for RTIs. Examples of such explanations reported in other studies include poor personal hygiene related to environmental contamination and lack of water, an adverse physical environment that contributes to exposure to dust, dirt, and cold, and excessive physical labour and other strenu-ous activities.



In this study, women described agents of contamination as microbes found in the dust and soil. This represents an area of common ground between local and 'cosmopoli-tan' or 'modern' medicine that may be targeted for preven-tion efforts. Both systems are concerned with preventing contact with illness causing agents, which both systems define as microbes. Since study participants seemed to understand the transmission of these microbes by sexual contact as well, this provides a good starting point for pre-vention efforts. Also, the perception that there is geo-graphic variation in the occurrence of RTIs is correct, and could be the starting point for dialog on RTIs, although there are important differences between perceived varia-tion and actual patterns of RTI prevalence as documented in recent prevalence surveys [4,5].

While further education about the causes, prevention and treatment of RTIs is warranted in this population, an argu-ment can also be made for also investing resources in the physical infrastructure of peri-urban communities, including provision of potable water, wastewater dis-posal, refuse collection and improvements in local trans-port. Interventions that address RTI education and prevention alongside legitimate environmental concerns of the community are likely to be effective in a population where the environmental deterioration is closely linked to poor health standards as is the case in Las Pampas. The reproductive health agenda cannot be divorced from envi-ronmental health problems.

Competing interests

There are no competing interests for this study. The study was funded in part by an ITREID training grant from the Fogarty Center, NIH (Bethesda, MD) and the RG-ER Anonymous Fund for Tropical Medicine Research, a pri-vate gift fund established by two American donors.

Authors' contributions

LSH performed many of the interviews, trained and super-vised other qualitative interviewers, coded and analyzed the data, and wrote the first draft of the paper. PJW pro-vided technical input to LSH, carried out the literature review including Table 1, and edited the final draft of the paper. KP wrote the final draft of the paper and assisted with the literature review. RHG conceived of the study, participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript


We would like to thank Lilia Cabrera and the health workers in the health centres for field and editorial assistance; Christie Lucas Gavin, MPH, Salva-tore Giorgianni, PharmD, Mark G. A. Opler, PhD, MPH, Jonny Platt, Seana Parker, Carmen Clarke MPH, Jaqueline Caoette, Katey Parker and Anne Griffin for editorial assistance; and J.B. Phu and D. Sara for technical

port. Special thanks to Margaret E. Bentley, PhD for her guidance and sup-port in planning this research study.


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Pre-publication history

The pre-publication history for this paper can be accessed here:


Table 1: Perceived causes of reproductive tract infections among informants reported in seven primarily qualitative studies
Table 2: Perceived relative abundance/frequency of reproductive tract infections in four different geographic areas, as assessed


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